| Doctor Name: | JOSEPH GRANVILLE JACKSON |
| NPI Number: | 1891152773 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | CCS, RAC |
| License Number: | 1300 |
| Business Practice Address: | 411 Sparrow St Lake Providence, LA - 712543035 |
| Business Phone Number: | 3185593356 |
| Business Fax Number: | 3185592044 |
| Mailing Address: | 706 Sparrow St, LAKE PROVIDENCE |
| State: | LA |
| Postal Code: | 712543520 |
| Phone Number: | 3185593356 |
| Fax Number: | 3185592044 |
| NPI Enumeration Date: | 01/22/2016 |
| NPI Last Update Date: | 01/22/2016 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YA0400X |
| License Number: | 1300 |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | LA |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Addiction (Substance Use Disorder) |
| Taxonomy Definition: | |